Monitoring cerebral oxygenation in traumatic brain injury
Introduction
Treatment of patients with severe traumatic brain injury (TBI) is largely focused on the prevention of secondary insults. Standard monitoring consists of measuring intra cranial pressure (ICP), (mean) arterial blood pressure (MAP) and thus calculating the cerebral perfusion pressure (CPP=MAP−ICP). This has led to ICP and CPP driven treatment protocols (Rosner et al., 1995; Nordstrom, 2005). However these measurements do not give further information on the existence of ischemia which is common in post mortem studies after TBI (Graham et al., 1978, Graham et al., 1989). Much effort has gone into the development of extra monitoring of the injured brain, so called multi modal monitoring (Unterberg et al., 1997; Meixensberger et al., 1998; Mulvey et al., 2004; De Georgia and Deogaonkar, 2005; Vespa, 2005). This review will focus on monitoring oxygenation in the injured brain. We will discuss the available technologies with special emphasis on brain tissue oxygen tension measurement, their (dis)advantages, the available clinical data with results of interventions with CPP and respiratory variations and will conclude summarizing our view of the future with these new technologies.
Section snippets
Global vs. focal monitoring
The different measurement modalities have different working areas. Some work very focally (e.g. brain tissue oxygen tension measurement) others globally (e.g. jugular bulb oxygenation). This leads to differences in their use and interpretation of their values (Sarrafzadeh et al., 1998; Gopinath et al., 1999; Bellander et al., 2004; Engstrom et al., 2005). The advantage of a global measurement is the information on a large part of the injured brain, more so because most treatments in TBI are
Jugular oximetry
Low SjVO2 values (below 50–55%) are related to poorer outcome (Gopinath et al., 1994; Fandino et al., 2000; Perez et al., 2003). The same holds for values higher than 75% (Cormio et al., 1999; Macmillan et al., 2001). Others have challenged these classic cut-off values after measurements in patients with Cushing syndrome (44.7–69.5%) (Chieregato et al., 2003). A limited improvement as opposed to clear improvement in increased AVDO2 after treatment is also related to poorer prognosis (Le Roux et
Technology comparisons
SjVO2 values correlate with IBV, defined as the area with CVO2 content ⩽3.5 ml/100 ml as measured by PET scan, with SjVO2 <50% occurring at IBV at 13±5% (Coles et al., 2004a).
In a study in 14 patients NIRS detected twice as many events as SjVO2 monitoring although the clinical significance of this is not known (Kirkpatrick et al., 1995). Another study found poor correlation between NIRS and SjVO2 monitoring even with SjVO2 desaturations below 55% (Lewis et al., 1996). In a study in 60 children
Summary and conclusions
ICP and CPP measurements alone are inadequate for detecting ischemia. The above-mentioned techniques can provide valuable information on oxygenation. An ideal technique (non-invasive, continuous, reliable and easy to use on the ICU) does not exist. To gain maximal insight the combination of a local and global monitor should suffice. However the advantages in outcome with extra measurements or targeted treatment have not yet been unequivocally proven. Any effort to do so should be stimulated and
Acknowledgments
The work of Dr. Haitsma is supported by NWO grant: 920-03-130. The Department of Neurosurgery, EMC, has received in natural support of research in neurocritical care from GMS mbh. (Kiel, Germany) and Codman/Johnson & Johnson (Raynham, MA, USA).
References (101)
- et al.
Cerebral interstitial tissue oxygen tension, pH, HCO3, CO2
Surg. Neurol.
(1997) - et al.
Correlations between brain tissue oxygen tension, carbon dioxide tension, pH, and cerebral blood flow--a better way of monitoring the severely injured brain?
Surg. Neurol.
(1998) - et al.
Cerebral oxygenation and systemic trauma related factors determining neurological outcome after brain injury
J. Clin. Neurosci.
(2000) - et al.
Ischaemic brain damage in fatal non-missile head injuries
J. Neurol. Sci.
(1978) - et al.
Effect of hypothermia on brain tissue oxygenation in patients with severe head injury
Br. J. Anaesth.
(2002) Oxygen toxicity
Crit. Care Clin.
(1990)Near infrared spectroscopy in brain injury: today's perspective
Acta Neurochir. Suppl.
(2005)Monitoring for neuroprotection. New technologies for the new millennium
Ann. N.Y. Acad. Sci.
(2001)- Bader, M.K., Littlejohns, L.R. and March, K. (2003). Brain tissue oxygen monitoring in severe brain injury, II....
- et al.
Monitoring of brain tissue PO2 in traumatic brain injury: effect of cerebral hypoxia on outcome
Acta Neurochir. Suppl.
(1998)
Consensus meeting on microdialysis in neurointensive care
Intensive Care Med.
CO2 reactivity and brain oxygen pressure monitoring in severe head injury
Crit. Care Med.
Normal jugular bulb oxygen saturation
J. Neurol. Neurosurg. Psychiatry
Comparison of two commercially available near-infrared spectroscopy instruments for cerebral oximetry. Technical note
J. Neurosurg.
Incidence and mechanisms of cerebral ischemia in early clinical head injury
J. Cereb. Blood Flow Metab.
Defining ischemic burden after traumatic brain injury using 15O PET imaging of cerebral physiology
J. Cereb. Blood Flow Metab.
Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates
Crit. Care Med.
Does induced hypertension reduce cerebral ischaemia within the traumatized human brain?
Brain
Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury
J. Neurosurg.
Elevated jugular venous oxygen saturation after severe head injury
J. Neurosurg.
Cerebral oxygenation. Monitoring and management
Acta Neurochir. Suppl.
On-line monitoring of global cerebral hypoxia in acute brain injury. Relationship to intracranial hypertension
J. Neurosurg.
Continuous monitoring of partial pressure of brain tissue oxygen in patients with severe head injury
Neurosurgery
The first decade of continuous monitoring of jugular bulb oxyhemoglobinsaturation: management strategies and clinical outcome
Crit. Care Med.
Cerebral autoregulation following head injury
J. Neurosurg.
Technical considerations in continuous jugular venous oxygen saturation measurement
Acta Neurochir. Suppl.
Jugular bulb oximetry: the link between cerebral and systemic management of severe head injury
Intensive Care Med.
Multimodal monitoring in the neurological intensive care unit
Neurologist
Brain tissue PO2 in relation to cerebral perfusion pressure, TCD findings and TCD-CO2-reactivity after severe head injury
Acta Neurochir.
Clinical experience with 118 brain tissue oxygen partial pressure catheter probes
Neurosurgery
Regional cerebrovascular and metabolic effects of hyperventilation after severe traumatic brain injury
J. Neurosurg.
No reduction in cerebral metabolism as a result of early moderate hyperventilation following severe traumatic brain injury
J. Neurosurg.
Determination of the ischemic threshold for brain oxygen tension
Acta Neurochir. Suppl.
Intracerebral microdialysis in severe brain trauma: the importance of catheter location
J. Neurosurg.
Correlation between jugular bulb oxygen saturation and partial pressure of brain tissue oxygen during CO2 and O2 reactivity tests in severely head-injured patients
Acta Neurochir.
Continuous measurement of jugular venous oxygen saturation in response to transient elevations of blood pressure in head-injured patients
J. Neurosurg.
Failure of the INVOS 3100 cerebral oximeter to detect complete absence of cerebral blood flow
Crit. Care Med.
Jugular venous desaturation and outcome after head injury
J. Neurol. Neurosurg. Psychiatry
Early detection of delayed traumatic intracranial hematomas using near-infrared spectroscopy
J. Neurosurg.
Near-infrared spectroscopic localization of intracranial hematomas
J. Neurosurg.
Comparison of jugular venous oxygen saturation and brain tissue PO2 as monitors of cerebral ischemia after head injury
Crit. Care Med.
Ischaemic brain damage is still common in fatal non-missile head injury
J. Neurol. Neurosurg. Psychiatry
Measuring brain tissue oxygenation compared with jugular venous oxygen saturation for monitoring cerebral oxygenation after traumatic brain injury
Anesth. Analg.
Advanced monitoring in the intensive care unit: brain tissue oxygen tension
Curr. Opin. Crit. Care
Brain oxygen monitoring: in-vitro accuracy, long-term drift and response-time of Licox- and Neurotrend sensors
Acta Neurochir. (Wien.)
Cerebral tissue PO2 and SjvO2 changes during moderate hyperventilation in patients with severe traumatic brain injury
J. Neurosurg.
The use of hyperventilation in the treatment of plateau waves in two patients with severe traumatic brain injury: contrasting effects on cerebral oxygenation
J. Neurosurg. Anesthesiol
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